Prospective Payment Systems Consultant - Remote

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

We are looking for an experienced consultant as an addition to the Optum Payment Integrity Practice. Responsibilities require solid understanding healthcare claims data, basic PPS concepts, UB04 and HCFA 1500 claim content, ability to conduct research of varying federal and states Medicaid regulations to determine hospital, ambulatory surgery, and physician provider reimbursement rules. Candidates must also demonstrate excellent data management and data quality skills.

AMS Consulting SME provides PI data analytic support including analytical/quantitative problem solving through data manipulation focused on statistical and PPS concepts. Provider reimbursement support via researching, compiling, interpreting, and developing specifications for testing/deploying custom pricing solutions for various federal and state Medicaid systems. Develop & deliver related training and education programs.

You’ll enjoy the flexibility to work remotely * from anywhere within the U.S. as you take on some tough challenges.

Primary Responsibilities:

Payment Integrity Data Analytic Support: Apply analytical / quantitative approach to problem solving related to claims lifecycle / adjudication
Support projects related custom consulting project in-scope deliverables
Knows how to obtain and use data, and comfortable with statistical concepts
Utilize communication skills to influence and negotiate
Utilize one’s solid interpersonal skills to work with all levels of management across all functional areas, as well as business partners through internal entities
Assist AMS SMEs with on-going development plans at the direction of leadership
Provider Reimbursement support: Researching, compiling, interpreting, documenting, developing appropriate specifications for testing and deploying custom pricing solutions
Assist Snr and Managing Consultants ongoing support of product training and education initiatives
Support delivery of customer training and education programs
Conducting regulatory research to determine revisions/updates to various federal and state Medicaid payment systems and updating the appropriate library of education materials to reflects current rule and regulations
Works directly with AMS regulatory SMEs customers to define other project requirements, provide assistance to answer questions related to project outcomes
Assist as needed with other claims pricing projects

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

Bachelor’s Degree or 2 years of experience with EasyGroup, Web. Strat or Rate Manager
2 years or experience working in a healthcare data or regulatory environment
Experience pricing Medicare hospital facility claims (inpatient and outpatient)across Medicare, Medicaid, Commercial
Experience breaking down information and developing solutions
Health plan or payment integrity experience in facility contract configuration, claims operations or IT
Experience documenting client operational and technical workflow
Experience healthcare claims data, basic PPS concepts, UB04 and HCFA 1500 claim content, EDI, 837i/837p
Experience with Microsoft Word, Excel, Visio
Advanced user level experience with PowerPoint; create new and update training collateral content
Understanding of Prospective Payment Systems - e.g. DRG, APC, OCE
Basic data management and data quality skills
Ability to conduct research on varying federal and states Medicaid regulations to determine hospital, ambulatory surgery, and physician provider reimbursement rules
Travel 25% of the time

Preferred Qualifications:

Experience configuring and customizing software solutions
Experience with EasyGroup, Payment System Interface, Web Services, Web.Strat or Rate Manager
Experience with Optum CES
Experience with Tableau
SQL experience - write queries, load tables, build output file
.NET or IIS experience
Claims system knowledge - Trizetto Facets, NetworX Pricer, QNXT, Health Rules Payer, IKA Claims, Burgess Systems, Epic Tapestry, 3M

Careers with Optum. Our objective is to make health care simpler and more effective for everyone. With our hands at work across all aspects of health, you can play a role in creating a healthier world, one insight, one connection and one person at a time. We bring together some of the greatest minds and ideas to take health care to its fullest potential, promoting health equity and accessibility. Work with diverse, engaged and high-performing teams to help solve important challenges.

California, Colorado, Connecticut, Nevada, New York, Rhode Island, or Washington Residents Only: The salary range for California, Colorado, Connecticut, Nevada, New York, Rhode Island or Washington residents is $67,800 to $133,100. Pay is based on several factors including but not limited to education, work experience, certifications, etc. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

*All employees working remotely will be required to adhere to UnitedHealth Group’s Telecommuter Policy

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.